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Although tens of thousands of Salmonella infections occur annually in this country, most involve the gastrointestinal tract with involvement of the urinary tract being quite infrequent.1-3 I would like to report a case of urosepsis due to Salmonella with eventual development of metastatic osteomyelitis of a rib that proved refractory to treatment. A 59-year-old Latin American male who resided in the Texas Rio Grande Valley presented to an emergency room with inability to void, having first noted a decreased urinary stream and dribbling a few months earlier. In-and-out bladder catheterization yielded 700 cc of urine, and he was sent out on co-trimoxazole one double-strength tablet twice daily. The patient returned within several hours, again unable to void, and a Foley catheter was inserted draining 1100 cc of urine. The patient was admitted for further evaluation. Past history was notable for long-standing inflammatory arthritis treated with injectable gold, hydroxychloroquine and nonsteroidal anti-inflammatory agents. He had previously undergone left shoulder replacement and synovectomy of both knees. Diabetes mellitus was diagnosed 6 years earlier and treated with oral hypoglycemic agents. The patient denied any gastrointestinal complaints. Examination was notable for a temperature of 102.4 degreesF and obvious sequelae of long-standing rheumatoid arthritis. The abdomen was entirely benign, but rectal examination revealed an enlarged, nontender prostate. White blood cell count was 11,200/mm3. Urinalysis revealed 10-12 white blood cells per high power field and 15-20 red blood cells per high power field. Two blood cultures from admission grew Salmonella species sensitive to all antibiotics. Urine cultured at the time of admission remained sterile. The patient was treated initially with tobramycin and ciprofloxacin and was changed to ceftriaxone 1 g intravenously every 12 hr when the Salmonella was identified. Ultrasound examination confirmed an enlarged prostate but disclosed no ureteral or renal abnormalities. Intravenous pyelogram also revealed the enlarged prostate but was otherwise unremarkable. On the ninth hospital day a transurethral resection of the prostate (TURP) was performed with histologic evidence of abscesses containing acute inflammatory cells in the resected tissue. The tissue itself was culture negative. He gradually defervesced and completed a 14-day course of parenteral therapy. The patient did well for about 6 months at which point he developed anterior chest wall pain for which he applied a heating pad. A second degree burn developed which ulcerated and began to drain. Culture revealed Salmonella species with a similar sensitivity pattern as the previous isolate. Local care as well as courses of oral ciprofloxacin and chloramphenicol failed to eradicate the drainage. The patient underwent surgical excision of the sinus tract 11 months after the initial bacteremia. Surgical specimens again grew Salmonella. Unfortunately, neither this nor the previous chest wall isolate was saved for further analysis. The area continued to drain and bone scan was consistent with osteomyelitis of the left sixth rib. Ceftriaxone 2 g intravenously per day was begun. The following month (16 months after the initial bacteremia) the patient underwent extensive debridement of the anterior chest wall with removal of the sixth and seventh ribs, and closure via a pectoralis myocutaneous flap. Forty-eight hours postoperatively, the patient suffered an acute myocardial infarction and expired. Postmortem revealed severe coronary artery disease. No additional focus of Salmonella infection was found.
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PMID:Salmonella Urosepsis Complicated by Metastatic osteomyelitis of the Chest Wall. 981 3

Septic arthritis is usually of hematogenous origin and is increasingly being reported in elderly patients, who often have underlying medical conditions such as diabetes or alcoholism. We report a 62-year-old patient with alcoholic liver disease who presented with Escherichia coli bacteremia and septic arthritis in a previously fractured ankle. There are scarce reports of infectious arthritis in cirrhotic patients, but this is the first report of arthritis after a primary enteric bacteremia. We believe that the patient described here developed E. coli bacteremia as a result of bacterial overgrowth and translocation related to alcoholic liver disease and cirrhosis. The resulting bacteremia resulted in the development of infection in the left ankle, which had preexisting disease and was thus vulnerable. This case provides further evidence for the mode of infection being bacteremia in cirrhotic patients. In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.
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PMID:Spontaneous bacterial arthritis in a cirrhotic patient. 985 73

At Asama General Hospital, we experienced six cases of urosepsis with septic shock during a period of five years between 1989 and 1993. All six patients, whose average age was 74 years old, recovered. In four patients, the condition was caused by obstructive uropathy. The remaining two cases were caused by renal inflammatory disease, which was complicated by diabetes mellitus. One of them was renal abscess with renal papillary necrosis, and the other was emphysematous pyelonephritis. The patients, who exhibited symptoms such as gram-negative bacteremia, severe hypotension, tachycardia, decrease of urine volume and mental disturbance, were diagnosed with urosepsis with septic shock. In all cases, symptoms such as a high fever of over 39 degrees C, hypoxemia and thrombocytopenia were observed. Renal dysfunction was found in 67%, and both liver dysfunction and disseminated intravascular coagulation (DIC) were found in 50% of the cases. Since no patients suffered from adult respiratory distress syndrome, a high survival rate was apparent. Anti-shock therapy and anti-coagulation therapy were ineffective for the patients who had septic shock due to urinary tract obstruction. Urinary tract drainage was required to treat the latter patients. Nephrectomy could not be avoided in renal parenchymatous inflammatory disease. In the future, what might be essential in therapeutics against urosepsis with septic shock, particularly to avoid nephrectomy, are the treatments such as immunotherapy against endotoxins and their mediators, and hemoperfusion for the removal of endotoxins.
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PMID:[Clinical study on 6 cases of urosepsis associated with septic shock]. 989 24

Helicobacter fennelliae (formerly Campylobacter fennelliae) has been reported to cause bacteremia in homosexual men with or without human immunodeficiency virus (HIV) infection. We report here a 48-year-old, non-HIV-infected, heterosexual man with diabetes mellitus and cirrhosis of the liver who developed bacteremia and septic shock due to H. fennelliae. The patient was treated successfully initially with intravenous ampicillin-sulbactam and ceftazidime, followed by ampicillin-sulbactam only. These agents were active in vitro against the isolate by E-test results. To our knowledge, this is the first documented case of septic shock due to H. fennelliae in a non-HIV-infected, heterosexual, immunocompromised patient.
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PMID:Septic shock due to Helicobacter fennelliae in a non-human immunodeficiency virus-infected heterosexual patient. 1032 88

We revised retrospectively 30 cases of Spontaneous Infectious Spondylodiskitis (SIS) in adults, diagnosed between 1986 and 1997. The mean age of the patients was 68.8 years; 56.7% were males. The identifiable causes were infectious endocarditis 13 (43.3%); tuberculosis 7 (23.3%); urinary tract infection 4 (13.3%); bacteremia with focus 2 (6.7%) and without focus 2 (6.7%). The cause was not identified in other 2 cases (6.7%). Infections were due to pyogenic bacteriae in 19 (63.3%); tuberculosis 6 (20%) and unknown 5 (16.7%). All patients had localized pain, 70% fever, 36.7% irradiated pain and 23.3% paraparesis. Fever was more frequent in patients with pyogenic etiology than in those with tuberculous SIS (p = 0.004). Blood cultures were positive in 70.4%. Percutaneous aspiration of the disc was performed in 13 patients; cultures were positive in 7. Causal germs were Streptococcus spp. 33.3%; Mycobacterium tuberculosis 20%; Staphylococcus spp. 16.6%; Escherichia coli 6.6%; Pseudomonas aeruginosa 6.6%. There was no bacteriological recovery in 5 (16.7%). Localization was lumbar in 18 (60%), dorsal in 8 (26.6%) and cervical in 4 (13.3%). X-ray of the spine was positive in 63.3% of the cases. Technetium scan in 90.5%, CT in 85.7% and MRI in 100% of cases in which it was carried out. All patients received antibiotic treatment with a median duration of 6 weeks for pyogenic SIS and one year for tuberculous SIS. Eighty three percent required immobilizing brace and 10% surgery for stabilization. Thirty six percent of patients presented complications, most of them related to the causal disease. There was a statistically significant association between mortality and diabetes.
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PMID:[Spontaneous infectious spondylodiscitis in adults. Analysis of 30 cases]. 1041 91

From July 1996 to June 1997, 22 adult patients with Serratia marcescens bacteremia were retrospectively studied at China Medical College Hospital. All patients had severe underlying disease, most commonly diabetes mellitus. Eighteen (82%) patients had nosocomial infection. Clinical syndromes included primary bacteremia (68%), pneumonia (14%), urinary tract infection (9%), suppurative thrombophlebitis (5%) and surgical wound infection (5%). Twelve patients had central venous catheters in place at the onset of bacteremia, but only one case met the definition of catheter-related infection. In 14 (64%) patients, portal of entry of S. marcescens infection was unknown. Five (23%) patients had concurrent polymicrobial bacteremia. The overall mortality rate was 50% (11/22). Seven (32%) of the 22 patients died of S. marcescens bacteremia. All isolates were resistant to ampicillin and cephalothin and susceptible to imipenem. Ninety-five percent of strains were susceptible to moxalactam, 68% to amikacin, 55% to ceftazidime, 45% to aztreonam, 32% to ceftriaxone, 27% to gentamicin, 18% to cefoperazone and cefotaxime, and 9% to piperacillin. MICs of various antibiotics demonstrated that ciprofloxacin and imipenem had good activities against S. marcescens, with MIC90 of 0.19 microg/mL and 1.0 microg/mL, respectively. Due to increasing multidrug resistance, choosing appropriate antimicrobial agents such as moxalactam, imipenem, and ciprofloxacin should be highly recommended for the treatment of S. marcescens infections.
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PMID:Serratia marcescens bacteremia: clinical features and antimicrobial susceptibilities of the isolates. 1049 54

Severe CAP is a life-threatening condition defined by the presence of respiratory failure or symptoms of severe sepsis or septic shock. It accounts for approximately 10% of hospitalized patients with CAP. The majority of patients with severe pneumonia have underlying comorbid illnesses, with COPD, alcoholism, chronic heart disease, and diabetes mellitus being the most frequent. S. pneumoniae, Legionella spp, GNEB (especially K. pneumoniae), H. influenzae, S. aureus/spp, Mycoplasma pneumoniae, respiratory viruses (especially influenza viruses), and P. aeruginosa represent the most important causative organisms of severe CAP. Rapid initiation of appropriate antimicrobial treatment is crucial for a favorable outcome. Initial antimicrobial treatment should be based on an epidemiological (empiric) approach. Microbial investigation may be helpful in the individual case but is probably more useful to define local antimicrobial policies based on local epidemiologic and susceptibility patterns. Mortality rates range from 21% to 54%. The most important prognostic factors include general health state of the patient, appropriateness of initial antimicrobial treatment, and the existence of bacteremia, as well as factors reflecting severe respiratory failure, severe sepsis, septic hypotension or shock, and the extent of infiltrates in chest radiograph. Initial antimicrobial treatment should consist of a second (or third) generation cephalosporin and erythromycin. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for distinct pathogens. Promising new approaches of nonantimicrobial treatment, including noninvasive ventilation, treatment of hypoxemia, and immunomodulation, are under investigation.
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PMID:Severe community-acquired pneumonia. 1051 5

Glucagon-like peptides (GLPs) are secreted from enteroendocrine cells in the gastrointestinal tract. GLP-1 actions regulate blood glucose, whereas GLP-2 exerts trophic effects on intestinal mucosal epithelium. Although GLP-1 actions are preserved in diseases such as diabetes, GLP-2 action has not been extensively studied in the setting of intestinal disease. We have now evaluated the biological effects of a human GLP-2 analog in the setting of experimental murine nonsteroidal antiinflammatory drug-induced enteritis. Human (h)[Gly(2)]GLP-2 significantly improved survival whether administered before, concomitant with, or after indomethacin. h[Gly(2)]GLP-2-treated mice exhibited reduced histological evidence of disease activity, fewer intestinal ulcerations, and decreased myeloperoxidase activity in the small bowel (P < 0.05, h[Gly(2)]GLP-2- vs. saline-treated controls). h[Gly(2)]GLP-2 significantly reduced cytokine induction, bacteremia, and the percentage of positive splenic and hepatic bacterial cultures (P < 0.05). h[Gly(2)]GLP-2 enhanced epithelial proliferation (P < 0.05 for increased crypt cell proliferation in h[Gly(2)]GLP-2- vs. saline-treated mice after indomethacin) and reduced apoptosis in the crypt compartment (P < 0.02). These observations demonstrate that a human GLP-2 analog exerts multiple complementary actions that serve to preserve the integrity of the mucosal epithelium in experimental gastrointestinal injury in vivo.
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PMID:Glucagon-like peptide 2 decreases mortality and reduces the severity of indomethacin-induced murine enteritis. 1056 23

Predictors of bacteremia and mortality in bacteremic liver transplant recipients were prospectively assessed. One hundred eleven consecutive episodes of fever or infections were documented in 59 patients over a 4-year period. Forty-nine percent (29 of 59 patients) of the patients had bacteremia, 39% (23 of 59 patients) had nonbacteremic infections, and 12% (7 of 59 patients) had fever of noninfectious cause. Primary (catheter-related) bacteremia (31%; 9 of 29 patients), pneumonia (24%; 7 of 29 patients), abdominal and/or biliary infections (14%; 4 of 29 patients), and wound infections (10%; 3 of 29 patients) were the predominant sources of bacteremia. Diabetes mellitus (odds ratio, 6.9; P =.03) and serum albumin level less than 3.0 mg/dL (odds ratio, 0.14; P =.02) were independently significant predictors of bacteremia compared with nonbacteremic infections. Mortality at 14 days was 28% (8 of 29 patients) in those with bacteremia compared with 4% (1 of 23 patients) in those with nonbacteremic infections and 0% (0 of 7) in patients with fever of noninfectious cause (P =.03). Intensive care unit stay at the time of bacteremia (100% v 47%; P =.005), absence of chills (0% v 53%; P =.005), lower temperature at the onset of bacteremia (99.2 degrees F v 101.5 degrees F; P =.009), lower maximum temperature during the course of bacteremia (99.3 degrees F v 102 degrees F, P =.008), greater serum bilirubin level (7.6 v 1.5 mg/dL; P =.024), presence of abnormal blood pressure (80% v 16%; P =. 0013), and greater prothrombin time (15.6 v 13.3 seconds; P =.013) were significantly predictive of greater mortality in the bacteremic patients. These data have implications for discerning the likelihood of bacteremia and initiation of empiric antibiotics pending cultures. Lack of febrile response in bacteremic liver transplant recipients portended a poorer outcome.
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PMID:Predicting bacteremia and bacteremic mortality in liver transplant recipients. 1064 78

Anaerobic infections are not commonly studied in the community hospital. The aim of this study was to determine demographic factors, the portals of entry and underlying disorders for clostridial bacteremia and to determine whether appropriate (recommended) treatment is effective. Medical records were reviewed for 42 patients with clostridial bacteremia at 1 Florida, USA, hospital and 4 Dayton, Ohio, USA, hospitals. Fourteen (33.3%) of the patients had clostridial micro-organisms that were isolated in cultures with polymicrobial isolates. Only about half of the patients had fever at the onset of their bacteremia and only slightly more than half had elevated leukocyte counts. The most common portals of entry for the micro-organisms were gastrointestinal (42.9%), unknown (35.7%) and skin (16.7%). The most common underlying disorders were advanced malignancy (31.0%), diabetes mellitus (14.3%), none determined (12.0%) and acute cholecystitis (9.5%). The mortality rate was 23.8%. Timely appropriate treatment was started in only about half of the instances. Appropriate (recommended) treatment did not significantly affect survival (p = 0.469). Clostridial infections and bacteremia exist in the community hospital most commonly in severely ill patients. The fact that clostridia are commonly cultured in blood cultures positive for other bacterial pathogens and that appropriate treatment for clostridia did not affect patient survival, call into question the significance and pathogenicity of clostridial organisms. On the other hand, if clostridial bacteremia was not considered in half these patients with bacteremia, it is possible that more indolent clostridial infections are being overlooked.
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PMID:Clostridial bacteremia in the community hospital. 1071 73


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